Healthcare Fraud

One of the most memorable lines to come out of the Watergate scandal is the adage – “follow the money.” This adage explains why state and federal prosecutor have turned their focus much more sharply towards prosecuting people suspected of committing healthcare fraud. In 1980, our country spent about $1,000 on healthcare per person, per year. By 2018 that number had eclipsed $10,000, and the growth has no signs of stopping anytime soon. Healthcare fraud charges – in both state and federal court – are serious.

What is Healthcare Fraud?

The federal statute regulating healthcare fraud is 18 U.S.C. § 1347. That law defines “healthcare fraud” very broadly – essentially covering any misconduct involving money in the healthcare field. People accused of healthcare fraud are unlike most other federal defendants. Charges are typically brought against medical doctors, chiropractors, or other people working in or around the medical insurance industry. The average age of people accused is 48 years old, and the accused almost always have little or no criminal record. Nevertheless, outcomes can be dire.

Charges & Penalties

The federal law allows a maximum sentence of ten years imprisonment per count of conviction. But that maximum rises to twenty years per count if a victim suffers “serious bodily injury” in connection with the charges, and there is no maximum – a potential life sentence – if a victim dies in connection with the charges. Federal healthcare fraud sentences are driven heavily by (1) whether the government can prove the accused committed “fraud” and (2), if so, the amount of money the judge determines was “defrauded” by the accused. Prosecutors are very aggressive in this area, especially when they perceive Medicare or Medicaid as being “victimized.” These cases frequently involve multiple counts and often pair a prison term with a heavy restitution order.

Impactful Cases

One high profile case was that of Dr. Jorge Martinez, an Ohio doctor who came under investigation because he was billing for significantly more nerve-block injections (used to manage pain) than his peers were. The government pursued him under the theory that he was over-medicating to maximize billings and therefore committed fraud. Further, two of his patients had died from overdoses, and the government pinned those deaths on him. He was charged with sixty counts, mostly of healthcare fraud, and convicted of over fifty counts. He was sentenced to life in prison and ordered to pay over $14 million in restitution.

Another example – with a less severe, but still harsh outcome – is of a Brooklyn Park doctor who was the billing agent for a home healthcare agency that provided RN services to Medicaid recipients. He was charged with over-billing Medicaid for his services. He pled guilty and was ordered to serve a term of 18 months in a federal prison followed by a two-year term of supervised release. He was also ordered to pay over $500,000 in restitution.

Healthcare Fraud in Minnesota

Outcomes can be similar when people are charged in Minnesota state courts, which group in healthcare fraud with insurance fraud (and with other theft charges generally). There, too, the outcome is driven heavily by the financial impact of the offense. Minnesota law allows a maximum sentence of up to twenty years on these matters.

On the other hand, sometimes prosecutors contemplate charges but do not bring them, and sometimes charges are brought but end up dropped, dismissed, or proven to be meritless. There exist a wide range of possible outcomes.

Healthcare Fraud Lawyers

Defending healthcare fraud charges requires the willingness to dive into complicated sets of facts and the skill to tell the other side of the story. A savvy and experienced lawyer can make a huge difference, whether that means beating the charges or having a “soft landing” that lets you move on with your life. Contact us today.

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Andrew Birrell

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